16394 DA Form 1 · OPW19/0242

PART 8 – CHECKLIST AND APPLICANT DECLARATION
 24) Development application checklist
 I have identified the assessment manager in question 15 and all relevant referral requirement(s) in
 question 17                                                                                             X Yes
 Note: See the Planning Regulation 2017 for referral requirements
 If building work is associated with the proposed development, Parts 4 to 6 of DA Form 2 – Building        Yes
 work details have been completed and attached to this development application                           X Not applicable
 Supporting information addressing any applicable assessment benchmarks is with development
 application
 Note: This is a mandatory requirement and includes any relevant templates under question 23, a          X Yes
 planning report and any technical reports required by the relevant categorising instruments (e.g.
 local government planning schemes, State Planning Policy, State Development Assessment
 Provisions). For further information, see DA Forms Guide: Planning Report Template.
 Relevant plans of the development are attached to this development application
 Note: Relevant plans are required to be submitted for all aspects of this development application.      X Yes
 For further information, see DA Forms Guide: Relevant plans.
 The portable long service leave levy for QLeave has been paid, or will be paid before a development       Yes
 permit is issued (see 21))                                                                              X Not applicable
 25) Applicant declaration
 X By making this development application, I declare that all information in this development application is true and correct
 X Where an email address is provided in Part 1 of this form, I consent to receive future electronic communications from the
 assessment manager and any referral agency for the development application where written information is required or permitted
 pursuant to sections 11 and 12 of the Electronic Transactions Act 2001
 Note: It is unlawful to intentionally provide false or misleading information.
 Privacy – Personal information collected in this form will be used by the assessment manager and/or chosen assessment
 manager, any relevant referral agency and/or building certifier (including any professional advisers which may be engaged by
 those entities) while processing, assessing and deciding the development application.
 All information relating to this development application may be available for inspection and purchase, and/or published on the
 assessment manager’s and/or referral agency’s website.
 Personal information will not be disclosed for a purpose unrelated to the Planning Act 2016, Planning Regulation 2017 and the DA
 Rules except where:
 • such disclosure is in accordance with the provisions about public access to documents contained in the Planning Act 2016 and
      the Planning Regulation 2017, and the access rules made under the Planning Act 2016 and Planning Regulation 2017; or
 • required by other legislation (including the Right to Information Act 2009); or
 • otherwise required by law.
 This information may be stored in relevant databases. The information collected will be retained as required by the Public
 Records Act 2002.


PART 9 – FOR OFFICE USE ONLY
 Date received:                                Reference number(s):

 Notification of engagement of alternative assessment manager
 Prescribed assessment manager
 Name of chosen assessment manager
 Date chosen assessment manager engaged
 Contact number of chosen assessment manager
 Relevant licence number(s) of chosen assessment manager

 QLeave notification and payment
 Note: For completion by assessment manager if applicable
 Description of the work
 QLeave project number
 Amount paid ($)
 Date paid
 Date receipted form sighted by assessment manager
 Name of officer who sighted the form




                                                                                                                              Page 10
                                                                                            DA Form 1 – Development Application details
                                                                                                          Version 1.1— 22 JUNE 2018